The impact of breast density notification on psychosocial outcomes in racial and ethnic minorities: A systematic review

BACKGROUND

High breast density is an independent risk factor for breast cancer and decreases the sensitivity of mammography. This systematic review synthesizes the evidence on the impact of breast density (BD) information and/or notification on women's psychosocial outcomes among women from racial and ethnic minority groups.

METHODS

A systematic search was performed in March 2023, and the articles were identified using CINHAL, Embase, Medline, and PsychInfo databases. The search strategy combined the terms "breast", "density", "notification" and synonyms. The authors specifically kept the search terms broad and did not include terms related to race and ethnicity. Full-text articles were reviewed for analysis by race, ethnicity and primary language of participants. Two authors evaluated the eligibility of studies with verification from the study team, extracted and crosschecked data, and assessed the risk of bias.

RESULTS

Of 1784 articles, 32 articles published from 2003 to 2023 were included. Thirty-one studies were conducted in the United States and one in Australia, with 28 quantitative and four qualitative methodologies. The overall results in terms of breast density awareness, knowledge, communication with healthcare professionals, screening intentions and supplemental screening practice were heterogenous across studies. Barriers to understanding BD notifications and intentions/access to supplemental screening among racial and ethnic minorities included socioeconomic factors, language, health literacy and medical mistrust.

CONCLUSIONS

A one-size approach to inform women about their BD may further disadvantage racial and ethnic minority women. BD notification and accompanying information should be tailored and translated to ensure readability and understandability by all women.

Consumer experiences of shame in clinical encounters for breast cancer treatment. "Who do you think you are- Angelina Jolie?"

BACKGROUND

Shame is a powerful negative emotion that has the potential to affect health. Due to the intimate nature of breast cancer treatment and its impact on body image, it is hypothesised that shame may be experienced during treatment. The aim of this study was to explore shame experiences related to clinical encounters for breast cancer treatment.

METHODS

People with a lived experience of breast cancer were invited to anonymously share their stories of shame through an online survey. Using qualitative methodology, the stories were examined, and themes identified.

PARTICIPANTS

Participants were members of the consumer organisation Breast Cancer Network Australia.

RESULTS

Stories were contributed by 38 participants. Most (n = 28, 73.7 %) were >5 years post-diagnosis. Shame was experienced in a range of clinical settings (consulting rooms, wards, operating theatres, radiotherapy departments). They involved a different health professionals (oncologists, surgeons, nurses, radiation therapists, psychologists.) Five themes were identified: (1) Body shame (sub-themes: Naked/vulnerable and Weight), (2) Communication (subthemes: Lack of compassion/impersonal manner and Not listening), (3) Being blamed (subthemes: diagnosis and complications), (4) Feeling unworthy (subthemes: Burden to staff and Unworthy of care), (5) Judgement for treatment choices.

CONCLUSIONS

Shame can be experienced in a range of situations, from scrutiny of the naked body to comments from health professionals. The impact of these experiences is profound, and the feelings of shame are carried for many years. These findings can inform strategies to support consumers and educate health professionals with the aim of reducing harm related to cancer treatment.

Psychosocial outcomes and health service use after notifying women participating in population breast screening when they have dense breasts: a BreastScreen Queensland randomised controlled trial

BACKGROUND

Robust evidence regarding the benefits and harms of notifying Australian women when routine breast screening identifies that they have dense breasts is needed for informing future mammography population screening practice and policy.

OBJECTIVES

To assess the psychosocial and health services use effects of notifying women participating in population-based breast cancer screening that they have dense breasts; to examine whether the mode of communicating this information about its implications (print, online formats) influences these effects.

METHODS AND ANALYSIS

The study population comprises women aged 40 years or older who attend BreastScreen Queensland Sunshine Coast services for mammographic screening and are found to have dense breasts (BI-RADS density C or D). The randomised controlled trial includes three arms (952 women each): standard BreastScreen care (no notification of breast density; control arm); notification of dense breasts in screening results letter and print health literacy-sensitive information (intervention arm 1) or a link or QR code to online video-based health literacy-sensitive information (intervention arm 2). Baseline demographic data will be obtained from BreastScreen Queensland. Outcomes data will be collected in questionnaires at baseline and eight weeks, twelve months, and 27 months after breast screening. Primary outcomes will be psychological outcomes and health service use; secondary outcomes will be supplemental screening outcomes, cancer worry, perceived breast cancer risk, knowledge about breast density, future mammographic screening intentions, and acceptability of notification about dense breasts.

ETHICS APPROVAL

Gold Coast Hospital and Health Service Ethics Committee (HREC/2023/QGC/89770); Sunshine Coast Hospital and Health Service Research Governance and Development (SSA/2023/QSC/89770).

DISSEMINATION OF FINDINGS

Findings will be reported in peer-reviewed journals and at national and international conferences. They will also be reported to BreastScreen Queensland, BreastScreen Australia, Cancer Australia, and other bodies involved in cancer care and screening, including patient and support organisations.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12623000001695p (prospective: 9 January 2023).

Reflections from Women with an Interval Breast Cancer Diagnosis: A Qualitative Analysis of Open Disclosure in the BreastScreen Western Australia Program

BACKGROUND

'Interval breast cancer' describes a malignancy that is diagnosed after a negative screening mammogram. Open disclosure is a process of addressing a negative health outcome that includes an apology and an opportunity for the client to discuss concerns. BreastScreen Western Australia has implemented a policy of open disclosure. The purpose of this study was to gain an understanding of clients' experience with interval cancer and their attitude towards the screening programme by conducting a thematic analysis of written responses from women participating in the open disclosure process.

METHODS

Women experiencing an interval cancer diagnosis between 2011 and 2020 were sent a questionnaire by mail. It included two broad questions with free-text responses. A qualitative analysis of the responses was conducted using an inductive approach. Responses were de-identified and data were thematically analysed and presented using verbatim quotations.

RESULTS

Five themes emerged in response to "what could we have done better?": 'nothing,' 'broaden scope,' 'service delivery,' 'breast density education' and 'more education' generally. Six themes emerged in response to "what did we do well?": 'staffing,' 'overall satisfaction,' 'reminders,' 'follow-up after interval cancer,' 'efficiency' and 'information and education provision.' An additional theme of 'storytelling' emerged from both questions: an opportunity for the woman to share her experience of cancer.

CONCLUSION

Most women expressed positive attitudes towards the service and appreciated giving feedback in the open disclosure process. Several themes supporting the role of BreastScreen in education were identified, including providing information about breast density, breast health, and limitations of screening.

The Impact of Breast Awareness on the Early Detection of Breast Cancer in Young Women: A Systematic Review

Background

"Breast awareness" is a recommendation that women understand the symptoms of breast cancer and become familiar with the usual look and feel of their breasts. It is recommended for women of all ages in breast cancer screening guidelines around the world. The objective of this study was to assess the evidence for breast awareness by investigating its effect on breast cancer outcomes in women of pre-mammographic-screening age (under age 40), at average risk of breast cancer.

Methods

A systematic review was performed using PRISMA methodology. Following the search, abstracts and full-text articles were assessed against eligibility criteria. Data were extracted into evidence tables, risk of bias was assessed, narrative synthesis was performed, and results were described. Eligible studies were original research studies assessing the impact of breast awareness on cancer outcomes (such as stage at diagnosis or survival) in women ≤40. Medline, PubMed, and Cochrane Library were searched.

Results

After screening the 6,204 abstracts identified in the search, no studies meeting all eligibility criteria were found. Two partially eligible studies were identified. These met the intervention and outcomes criteria but included mixed-age cohorts that included but were not limited to women ≤40. These studies provided low-level (Level IV) evidence of moderate quality that there is some benefit (earlier stage at diagnosis and/or improved survival) of breast awareness in a mixed-age cohort that included some younger women.

Conclusions

No studies evaluating the impact of breast awareness exclusively in young women were identified. Limited evidence of benefit of breast awareness was found. Guidelines that recommend breast awareness should be reviewed and qualified with an explanation that the evidence of benefit is weak. Women have limited screening options available to them for the early detection of breast cancer until they reach mammographic screening age. The study was registered on Prospero (ID: CRD42021279457).

Inaugural roundtable on breast reconstruction practice in Australia: background, process and recommendations

Recommendations from the inaugural roundtable on breast reconstruction held on 9 October 2019 in Queensland, Australia, for improved decision-making and increased funding to support wider, timely access to breast reconstruction.

Symptoms of anxiety, depression and fear in healthcare workers and non-healthcare workers undergoing outpatient COVID-19 testing in an urban Australian setting

This study assessed symptoms of anxiety, depression and fear of COVID-19 in members of the general community and healthcare workers (HCWs) attending for COVID testing. This cross-sectional study was conducted in a public hospital COVID-19 testing clinic (June-September 2020) using self-administered questionnaires (i.e. the Hospital Anxiety and Depression Scale (HADS) and the Fear of COVID-19 Scale). In all, 430 participants who met the criteria for COVID-19 testing with nasopharyngeal and throat swabs completed the questionnaires. The mean (±s.d.) age of participants was 37.6 ± 12.6 years. HCWs made up 35.1% of the sample. Overall, the mean (±s.d.) score for anxiety was 6.09 ± 4.41 and 'case' prevalence (any severity) was 151/430 (35.1%), higher than normative population scores. Higher anxiety was found in women (P = 0.001) and in clients who had previously been tested for coronavirus (P = 0.03). HCWs had lower anxiety scores than members of the general community (P = 0.001). For depression, the mean (±s.d.) score was 4.18 ± 3.60, with a 'case' prevalence (any severity) of 82/430 (19.1%), similar to normative population scores. Women reported a higher level of COVID-19 fear (P = 0.001), as did people with a lower education level (P = 0.001). A greater psychological impact of COVID-19 was observed in women, people undergoing repeat testing and participants reporting lower levels of educational attainment. HCWs had fewer symptoms of anxiety and depression than non-HCWs attending the same clinic for COVID-19 testing. This information can be used to plan mental health interventions in primary care and testing settings during this and future pandemics.

The Effect of Supplemental Imaging on Interval Cancer Rates in Mammography Screening: Systematic Review

Supplemental screening with MRI or ultrasound increases cancer detection rate (CDR) in women with standard screening mammography. Whether it also reduces interval cancer rate (ICR) is unclear. This study reviewed the evidence evaluating the effect of supplemental imaging on ICR in women undergoing screening mammography. This systematic review included studies that reported both CDR and ICR in women undergoing screening mammography alone compared to those undergoing screening mammography with supplemental imaging. Five studies (3 randomized trials) were eligible. These reported on 142,153 women undergoing mammography screening alone or mammography with supplemental imaging (3 ultrasound and 2 MRI studies). Two studies included a general screening population and 3 included special populations (young, high genetic risk and/or dense breasts). The incremental CDR for supplemental MRI was 14.2 to 16.5/1000 screens and for ultrasound was 0 to 4.4/1000 screens. Effect on ICR was variable but evidence of a reduced ICR was more consistent for studies using supplemental MRI (ICR 0.3 to 0.8 per 1000 screens) than those using ultrasound (ICR 0.49 to 1.9 per 1000 screens). The higher CDR and lower ICR with supplemental screening were associated with higher recall and biopsy rates particularly with supplemental MRI (9.5%-15.9%, up to 69/1000 screens). Cancers detected with supplemental imaging modalities were generally smaller and earlier stage. Mammography with supplemental MRI or ultrasound increases detection of cancers (versus mammography only) in some sub-groups but also increases recall and biopsy rates and may have a relatively modest effect in reducing ICR.

Granulomatous lobular mastitis: Clinical update and case study

BACKGROUND

Granulomatous lobular mastitis (GM) is a rare chronic benign inflammatory breast condition. It can present a diagnostic challenge and mimic inflammatory carcinoma. It causes significant morbidity for affected patients.

OBJECTIVE

The aim of this article is to provide a clinical update and case study for general practitioners, who are usually the first to see the patient.

DISCUSSION

GM is usually idiopathic. The condition presents with a large painful lump with erythema. There is often ulceration, abscess and sinus formation. Triple assessment is needed to confirm diagnosis. GM may last for 12 months or more before healing occurs. Options for management are conservative/supportive care, oral prednisone or methotrexate, or surgical excision. At present, there is no universally accepted management strategy for GM; therefore, treatment will depend on the symptoms, extent of disease and patient preferences. Supporting the patient in coping with the long-term nature of GM and the chronic discharging lesions is essential.

Update on the management of early-stage breast cancer

BACKGROUND

Breast cancer affects one in eight Australian women. While surgery, chemotherapy, radiotherapy and endocrine therapy are still the main treatments, there have been changes in the sequencing of treatment and advances in each therapy. The general practitioner (GP) is involved at each stage of the patient's journey.

OBJECTIVE

This article discusses the current approach to the management of early breast cancer. It focuses on changes in recent years and discusses the role of the GP in supporting women in their decision-making and treatment.

DISCUSSION

Key changes include the increasing use of neoadjuvant chemotherapy, the development of advanced oncoplastic surgery and breast reconstruction techniques, the use of gene expression profiling and the recommendation for extended adjuvant endocrine therapy for up to 10 years.

Features of Breast Cancer in Iranian-born Migrant Women Treated in Australia

Background: While there is much information available about breast cancer in Australia overall, less is known about breast cancer in immigrant women and specifically Iranian-born women. Understanding this group is important to provide appropriate screening, treatment and support interventions. The aim of this study was to describe breast cancer presentation, tumour and treatment characteristics in Iranian-born women in Australia. Methods: Women were eligible for this retrospective audit if treated for breast malignancy with country of birth recorded. Demographic, tumour and surgical data were extracted and analysed. Data for Iranian-born women were compared to data for Australian-born (comparison group 1) and women born in countries other than Australia or Iran (comparison group 2, referred to as ‘other’). Results: 2086 women were eligible: Iranian-born n=27, Australian-born n=894 and Other n=1165. Iranian-born women were younger, mean age of 53.9 (five years younger in overall mean, SD 11.98, F=3.171, p=0.042). Iranian-born women were significantly less likely to present with a screen-detected cancer (X2= 11.481, p=0.003) and more likely to have a high-grade cancer (X2=14.383, p=0.006). There was no difference in mastectomy rate (X2=1.698, p=0.428).Conclusion: Iranian-born women treated for breast cancer in Australia were younger, had higher-grade tumours and were less likely to have a screen-detected cancer than Australian-born women or women born in other countries. Strategies to encourage screening participation in Iranian-born women are required. Support for these women is required as they are more likely to receive toxic treatments (chemotherapy and extended adjuvant endocrine therapy) due to younger age and higher grade tumours.

Contralateral prophylactic mastectomy for unilateral breast cancer in women at average risk: Systematic review of patient reported outcomes

OBJECTIVE

The rate of contralateral prophylactic mastectomy (CPM) in women with early, unilateral cancer is relatively high and is increasing around the world a previous study. Women choose this option for many reasons other than reducing their risk of future cancer, including symmetry, reasons related to breast reconstruction and attempting to manage fear of recurrence. This systematic review evaluated patient-reported quality of life outcomes following CPM.

METHODS

A literature search of MEDLINE, PubMed and PsycINFO was performed to February 2019. Abstracts and full-text articles were assessed for eligibility according to pre-determined criteria. Data were extracted into evidence tables for analysis.

RESULTS

A total of 19 articles met eligibility criteria and were included in analysis. These included patient-reported data from 6088 women undergoing CPM. They reported high levels of satisfaction with the decision for surgery, low levels of decisional regret and high satisfaction with cosmesis and reconstruction. Breast-specific and general quality of life was high overall but was even better in women choosing breast reconstruction after surgery. Fear of cancer recurrence was high after CPM. Depression, distress and a negative impact on body image were evident; however, levels were high in both CPM and non-CPM groups.

CONCLUSIONS

This study provides information that can be used by surgeons and psychologists when counselling women about the potential benefits and harms of CPM. This process must include discussion about the trade-offs such as body image issues and ongoing fear of recurrence in addition to the positive aspect of cancer risk reduction. Women are unlikely to regret their decision for CPM.

The Emergence of Breast Care Nursing in A Developing Nation: A Sri Lankan-Australian Training Partnership

Objective:

In Sri Lanka, the incidence of breast cancer is increasing. Yet, Sri Lankan nurses have limited specialist education opportunities and no formal recognition of the breast care nurse (BCN) role to address this growing need. This project aimed to encourage the emergence of the BCN role in Sri Lanka by delivering a workshop for nurses to increase the knowledge and confidence in delivering breast cancer care.

Methods:

This project was initiated by Zonta, a nonprofit, service organization, in collaboration with the National Cancer Control Programme of the Ministry of Health, Nutrition and Indigenous Medicine, Sri Lanka. A 2-day intensive workshop was designed by a collaborative team of Australian and Sri Lankan health professionals and delivered in Colombo. Its effectiveness was evaluated by measuring the knowledge about breast cancer, confidence with clinical care, and satisfaction with the workshop.

Results:

Fifty nursing participants attended the workshop. Outcomes included a statistically significant increase in knowledge about breast cancer (P = 0.012) and confidence in clinical care (P < 0.003 for all aspects of confidence). All participants were highly satisfied with the workshop, agreeing that the content was relevant and that they developed new skills.

Conclusions:

Nurses in Sri Lanka have unmet needs for specialty training and education. A 2-day workshop can improve knowledge and confidence, with the potential to improve patient care and increase the recognition of the BCN role. Lessons learnt from the collaboration between the nongovernment and government partners provide a model for the development of specialist nursing education.

Presentation, tumour and treatment features in immigrant women from Arabic-speaking countries treated for breast cancer in Australia

BACKGROUND

Australia has a large population of immigrant women from Arabic-speaking countries. The aim of this study was to examine breast cancer tumour and surgical treatment features for women born in Arabic-speaking countries and compare them to women born in Australia and other countries. Another aim was to consider how this information can inform clinical care for this multicultural population.

METHODS

This is a retrospective audit of an institutional breast cancer database. Demographic, tumour and surgical treatment data were extracted for the Arab women and compared to Australian-born women (comparison 1) and to women born in all other countries (comparison 2); chi-squared analysis was performed to test for differences between groups.

RESULTS

A total of 2086 cases with country of birth information were identified, of whom 139 women (6.7%) were born in Arabic-speaking countries, 894 (42.8%) were born in Australia and 1053 (50.4%) were born in other countries (71 nations). Arab women tended to be younger (P = 0.013), more disadvantaged (P < 0.001), were more likely to have symptomatic rather than screen-detected breast cancer (P < 0.001), had a higher rate of high grade (P = 0.021), HER2-positive (P = 0.025) breast cancer compared to Australian-born women or others. There was no difference in tumour (pT) stage, rate of breast conservation versus mastectomy, re-excision and contralateral prophylactic mastectomy between groups. Australian-born women were more likely to undergo breast reconstruction after mastectomy (P < 0.001); reconstruction rate was >29% in all groups.

CONCLUSION

Women born in Arabic-speaking countries were younger, more disadvantaged and showed more aggressive tumour features. This has implications for supportive care during treatment and survivorship.

Breast symptoms in adolescents and young adults presenting to a specialist breast clinic

BACKGROUND AND OBJECTIVES

While breast cancer is rare in adolescents and young adults (AYAs), breast symptoms are common. The aim of this study was to report breast symptoms that prompted referral of AYAs and to examine diagnoses and treatment.

METHOD

A retrospective study of AYAs aged ≤25 years who presented in a specialist breast clinic (2007-18) was conducted. Data regarding presentation, diagnosis and management were collected.

RESULTS

One hundred and thirty-four (128 female, six male) AYAs, with a median age of 21 years, attended the breast clinic in the study period. There was one case of breast cancer (incidence 0.8%). In females, the most frequent presenting symptoms were 'lump' (n = 68, 53.1%), 'nipple/areola symptom' (n = 14, 10.9%) and 'discuss risk of breast cancer' (n = 10, 8.3%). In males, 'lump' was the most common presenting symptom (n = 5, 83%) and all were cases of gynaecomastia.

DISCUSSION

A range of breast symptoms are found in AYAs and most can be treated conservatively. Awareness of symptoms and their management will help general practitioners treat young people with breast issues.

Outcomes of breast reconstruction in older women: patterns of uptake and clinical outcomes in a large metropolitan practice

BACKGROUND

Older age is associated with lower rates of breast reconstruction (BR) following mastectomy. This study compared a range of factors in women aged 60 years and older who had received mastectomy and BR with those who received no BR (NBR).

METHODS

An audit of 338 women aged 60 or over treated with mastectomy with (n = 86) or without (n = 252) BR for primary breast cancer from 2009 to 2016 was conducted. Demographic, tumour, treatment, comorbidity and surgical complication data were obtained from patient medical records.

RESULTS

NBR patients were associated with older age (P ≤ 0.001), more comorbidities (P = 0.038) and more extensive disease (P = 0.001) than BR patients. Total number of complications was not significantly different between BR and NBR patients (P = 0.286), or the different types of BR (P = 0.697). BR patients had higher rates of unplanned returns to the operating theatre, particularly in the late post-operative period (P = 0.025). Implant-based reconstruction was associated with more unplanned operating theatre returns than autologous reconstruction in the late post-operative period (P = 0.013).

CONCLUSION

Post-mastectomy BR in elderly patients has a clinical complication profile similar to NBR patients. This audit found no clinical-based reasons to not offer oncologically suitable and clinically fit elderly women the option of BR.

The impact on Australian women of lack of choice of breast reconstruction options: A qualitative study

BACKGROUND

Many studies have demonstrated the positive impact of breast reconstruction (BR) on women following mastectomy for breast cancer. However, women's preferences for BR are not always considered by surgeons prior to mastectomy. The aim of this research is threefold: to document the negative impact lack of choice has had on some Australian women; to explore potential reasons for the absence of informed discussion; and to develop a prompt list of discussion topics to aid informed decision making.

METHODS

This research is part of a larger study using semistructured telephone or face-to-face interviews with women with breast cancer, surgeons, and health professionals to explore ways of improving access to BR. This article focuses on responses from all 22 women who reported negative BR experiences and seven of 31 surgeons who had made comments relevant to limiting BR discussion and choice.

RESULTS

The impact of a lack of information or choice at the time of mastectomy was often extreme and long-term. Breast surgeons are the gate keepers to accessing BR but too often appeared to limit women's choices. Interviews revealed cases where BR was not offered prior to mastectomy, even though it was available locally; where BR was not available locally, but patients were not informed about BR options available in other locations; where only delayed BR options were discussed; and where the type of BR being offered did not match patient preferences.

CONCLUSION

We have suggested essential BR discussion points to be raised with all clinically eligible women interested in considering BR.

Patient-reported outcomes of breast reconstruction in older women: Audit of a large metropolitan public/private practice in Sydney, Australia

OBJECTIVE

Older age is associated with lower rates of breast reconstruction (BR) for women requiring mastectomy. This study compared patient-reported outcomes between women aged 60 years and older who had received mastectomy and BR with those who received no BR (NBR).

METHODS

About 135 women aged 60 or over treated between 2009 and 2016 with mastectomy only (N = 87) or mastectomy with BR (N = 48) for primary breast cancer completed patient-reported outcome measures using a set of validated questionnaires. Reasons for choosing or declining BR were also explored using a set of nonvalidated questionnaires.

RESULTS

Patients who received BR were generally younger (P = <0.001) and reported greater satisfaction with their bodies (P = 0.048) than NBR patients. Patients with autologous reconstruction reported greater satisfaction with their breasts than implant-based reconstruction patients. Both BR and NBR patients reported good quality of life, low pain scores, good body image, and low levels of decisional regret.

CONCLUSIONS

These data do not identify any quality of life-related reasons to not offer clinically fit, well-informed older women the option of BR.

Regional variation in immediate breast reconstruction in Australia

Background

Breast reconstruction following mastectomy has proven benefits and is the standard of care in many high‐income countries. This audit documented regional variation in immediate breast reconstruction rates across Australia.

Methods

The Breast Surgeons of Australia and New Zealand (BreastSurgANZ) Quality Audit database and geospatial software were used to model the distribution of breast reconstructions performed on women having mastectomy in Australia in 2013. Geospatial mapping identified the distribution of these procedures in relation to the Greater Capital City Statistical Areas (GCCSAs) of the five largest states. Data were analysed using χ² tests of independence and an independent‐samples t test.

Results

Of 3786 patients having a mastectomy, 692 underwent breast reconstruction of which 679 (98·1 per cent) were immediate reconstructions. Rates of reconstruction differed significantly between jurisdictions (χ² = 164·90), and were significantly higher in GCCSAs (χ² = 144·60) and private hospitals (χ² = 50·72) (all P < 0·001). Immediate breast reconstruction was not reported for 43·8 per cent of hospitals where mastectomy was conducted by members of BreastSurgANZ, including 29·8 per cent of hospitals within GCCSAs. A wider age range of women appeared to have had immediate reconstructions at hospitals within GCCSAs, although the difference in mean age between regions was not significant. Immediate breast reconstruction was considerably less likely to be performed in women who lived in areas of lower to mid socioeconomic status.

Conclusion

Variations in the rate of immediate breast reconstruction may not be purely resource‐driven.

The role of clinical breast examination in cancer screening for women at average risk: A mini review

As the debate about the potential benefits and harms of screening mammography continues, it is timely to consider the role of clinical breast examination in screening for women at average risk of breast cancer. This article reviews the results from clinical trials and discusses the varied recommendations around the world. It concludes that the evidence does not support routine clinical breast examination for women participating in screening mammography programs, but there may be a benefit for women not do not have mammographic screening, especially in developing nations where health literacy and 'breast awareness' levels may be lower. This review provides information for clinicians to support women who are making decisions about the increasingly complex issue of breast cancer screening.

Meta-analysis of magnetic resonance imaging in detecting residual breast cancer after neoadjuvant therapy

BACKGROUND

It has been proposed that magnetic resonance imaging (MRI) be used to guide breast cancer surgery by differentiating residual tumor from pathologic complete response (pCR) after neoadjuvant chemotherapy. This meta-analysis examines MRI accuracy in detecting residual tumor, investigates variables potentially affecting MRI performance, and compares MRI with other tests.

METHODS

A systematic literature search was undertaken. Hierarchical summary receiver operating characteristic (HSROC) models were used to estimate (relative) diagnostic odds ratios ([R]DORs). Summary sensitivity (correct identification of residual tumor), specificity (correct identification of pCR), and areas under the SROC curves (AUCs) were derived. All statistical tests were two-sided.

RESULTS

Forty-four studies (2050 patients) were included. The overall AUC of MRI was 0.88. Accuracy was lower for "standard" pCR definitions (referent category) than "less clearly described" (RDOR = 2.41, 95% confidence interval [CI] = 1.11 to 5.23) or "near-pCR" definitions (RDOR = 2.60, 95% CI = 0.73 to 9.24; P = .03.) Corresponding AUCs were 0.83, 0.90, and 0.91. Specificity was higher when negative MRI was defined as contrast enhancement less than or equal to normal tissue (0.83, 95% CI = 0.64 to 0.93) vs no enhancement (0.54, 95% CI = 0.39 to 0.69; P = .02), with comparable sensitivity (0.83, 95% CI = 0.69 to 0.91; vs 0.87, 95% CI = 0.80 to 0.92; P = .45). MRI had higher accuracy than mammography (P = .02); there was only weak evidence that MRI had higher accuracy than clinical examination (P = .10). No difference in MRI and ultrasound accuracy was found (P = .15).

CONCLUSIONS

MRI accurately detects residual tumor after neoadjuvant chemotherapy. Accuracy was lower when pCR was more rigorously defined, and specificity was lower when test negativity thresholds were more stringent; these definitions require standardization. MRI is more accurate than mammography; however, studies comparing MRI and ultrasound are required.

Evaluation of the evidence on staging imaging for detection of asymptomatic distant metastases in newly diagnosed breast cancer

While guidelines recommend against routine use of staging imaging to detect asymptomatic distant metastases (DM) in newly diagnosed breast cancer (BC), modern imaging technologies may have improved detection capability and may have a role in some cases. We performed a systematic review of studies (1995-2011) evaluating the prevalence of DM and the accuracy of staging imaging for detection of asymptomatic DM. Twenty-two studies reporting on 14,824 BC subjects (median age 53 years) undergoing staging imaging were eligible. Median prevalence of DM was 7.0% (range 1.2-48.8%); prevalence increased with increasing BC stage. Conventional imaging studies had lower DM prevalence than studies of PET(PET/CT). Imaging median sensitivity/specificity respectively were: combined conventional imaging 78.0%/91.4%; bone scintigraphy 98.0%/93.5%; chest X-ray 100%/97.9%; liver ultrasound 100%/96.7%; CT chest/abdomen 100%/93.1%; FDG-PET 100.0%/96.5%; FDG-PET/CT 100%/98.1%. Low prevalence of DM was seen in Stage I-II BC with much higher prevalence in more advanced disease. Accuracy of PET modalities was very high however the high proportion of detected asymptomatic DM partly reflects selection bias.

Meta-analysis of the impact of surgical margins on local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy

PURPOSE

There is no consensus on what constitutes adequate negative margins in breast-conserving therapy (BCT). We review the evidence on surgical margins in BCT for early-stage invasive breast cancer.

METHODS

Meta-analysis of studies reporting local recurrence (LR) relative to quantified final microscopic margin status and the threshold distance for negative margins. The proportion of LR was modelled using random effects logistic meta-regression.

RESULTS

Based on 21 studies (LR in 1,026 of 14,571 subjects) the odds of LR were associated with margin status [model 1: odds ratio (OR) = 2.02 for positive/close versus negative; model 2: OR = 1.80 for close versus negative, 2.42 for positive versus negative (P<0.001 both models)] but not with margin distance [1mm versus 2mm versus 5mm (P > 0.10 both models)], adjusting for median follow-up time. However, there was weak evidence in both models that the odds of LR decreased as the threshold distance for declaring negative margins increased. This bordered significance in model 2 [OR for 1mm, 2mm, 5mm: 1.0, 0.75, 0.51 (P = 0.097 for trend)], and was not significant in model 1 [OR for 1mm, 2mm, 5mm: 1.0, 0.85, 0.58 (P = 0.11 for trend)] but was evident when one study (of women ≤ 40 years) was excluded from this model [OR for 1mm, 2mm, 5mm: 1.0, 0.72, 0.52 (P = 0.058 for trend)]: this trend was rendered insignificant by adjustment for the proportion of subjects receiving a radiation boost or the proportion of subjects receiving endocrine therapy.

CONCLUSIONS

Margin status has a prognostic effect in all women treated for invasive breast cancer; increasing the threshold distance for declaring negative margins is weakly associated with reduced odds of LR, however adjustment for covariates (adjuvant therapy) removes the significance of this effect. Adoption of wider margins, relative to narrower widths, for declaring negative margins is unlikely to a have substantial additional benefit for long-term local control in BCT.

Ductal carcinoma in situ at core-needle biopsy: meta-analysis of underestimation and predictors of invasive breast cancer

PURPOSE

To perform a meta-analysis to report pooled estimates for underestimation of invasive breast cancer (where core-needle biopsy [CNB] shows ductal carcinoma in situ [DCIS] and excision histologic examination shows invasive breast cancer) and to identify preoperative variables that predict invasive breast cancer.

MATERIALS AND METHODS

Studies were identified by searching MEDLINE and were included if they provided data on DCIS underestimates (overall and according to preoperative variables). Study-specific and pooled percentages for DCIS underestimates were calculated. By using meta-regression (random effects logistic modeling) the association between each study-level preoperative variable and understaged invasive breast cancer was investigated.

RESULTS

Fifty-two studies that included 7350 cases of DCIS with findings at excision histologic examination as the reference standard met the eligibility criteria and were included. There were 1736 underestimates (invasive breast cancer at excision); the random-effects pooled estimate was 25.9% (95% confidence interval: 22.5%, 29.5%). Preoperative variables that showed significant univariate association with higher underestimation included the use of a 14-gauge automated device (vs 11-gauge vacuum-assisted biopsy, P = .006), high-grade lesion at CNB (vs non-high grade lesion, P < .001), lesion size larger than 20 mm at imaging (vs lesions ≤ 20 mm, P < .001), Breast Imaging Reporting and Data System (BI-RADS) score of 4 or 5 (vs BI-RADS score of 3, P for trend = .005), mammographic mass (vs calcification only, P < .001), and palpability (P < .001).

CONCLUSION

About one in four DCIS diagnoses at CNB represent understaged invasive breast cancer. Preoperative variables significantly associated with understaging include biopsy device and guidance method, size, grade, mammographic features, and palpability.

Accuracy of sentinel lymph node biopsy in large and multifocal/multicentric breast carcinoma--a systematic review

BACKGROUND

While sentinel lymph node biopsy (SLNB) is established in the management of small unifocal breast cancer its role in management of multifocal (MF), multicentric (MC) and larger tumors is still evolving.

METHODS

Medline was searched; studies meeting pre-determined criteria were included. Data were extracted and entered into evidence tables.

RESULTS

Twenty six studies met inclusion criteria and reported data on accuracy; no randomized trials were identified. For MF cancers (n = 314 cases), success rate for identification of an SLN was 86-94%, SLN positivity rate 42-59%, false negative rate (FNR) 0-33% and overall accuracy 78-100%. For MC (n = 294 cases): success rate 92-100%, SLN positivity rate 25-61%, FNR 4-8% and accuracy 96-100%. For 'multiple breast cancer' (studies combining MF/MC cases; n = 996 cases): success rate 92-100%, SLN positivity rate 12-63%, FNR 0-25%, and accuracy 82-100%. For larger tumors (n = 1912 cases): success rate 86-100%, SLN positivity rate 49-77%, FNR 3-18% and accuracy 85-98%. For MC/MF and larger cancers overall non-SLN positivity rates were up to 82%; axillary recurrence rates were low but seldom reported.

CONCLUSION

There are no randomized trials evaluating the safety of SLNB in MF/MC and larger breast cancers. Based on limited evidence, success rate and FNR appear to be similar to those for small unifocal cancers, however node positivity rates are higher and rates of non-SLN positivity are very high. Awareness of these issues is essential when recommending SLNB based axillary management for these higher-risk tumors.

Abstract P1-01-03: Accuracy of Sentinel Lymph Node Biopsy in Large and Multifocal/Multicentric Breast Carcinoma — Systematic Review

Introduction: Sentinel lymph node biopsy (SLNB) is well established for management of small unifocal breast cancers. As confidence in SLNB increases, use of SLN-based management has increased and it is now often used for axillary staging in cases of multifocal (MF) and multicentric (MC) breast cancer and larger tumors although its role in the management of these tumors is controversial.

The aim of this study is to systematically review the evidence for SLNB in axillary staging for newly diagnosed invasive breast cancer that is MF/MC or greater than 30mm in diameter. Studies reporting accuracy of SLNB in these situations are reviewed and implications for patient management are discussed.

Methods: Medline was searched, identifying 3,461 studies of SLNB in breast cancer. Of these, 57 abstracts met the eligibility criteria which were: (a) original studies that reported (b) outcomes of SLNB in invasive breast cancer and (c) outcomes separately for a population of women with tumors that were either MF/MC or diameter 30mm or greater. Following review of full text articles, 36 studies were excluded as they did not meet criteria; two more studies were added after review of reference lists. Results: 23 studies met inclusion criteria and reported 20,687 cases of SLNB. This included data on accuracy for 1,541 MF, 369 MC, and 1,646 larger tumors. All included studies were case series; no randomized controlled trials were identified. Injection for lymphatic mapping was variably performed in site and technique and was variably reported. For MF cancers (n=976; 8 studies), success rate for identification of a SLN was 86-100%, SLN positivity rate 42-59%, false negative rate (FNR)

6-33%(with 4 of the 7 case series reporting false negative rates over 21%). The overall accuracy for MF tumors was 75-97%. For MC cancers (n=262; 4 studies): success rate for identification of a SLN 92-96%, SLN positivity rate 50-61%, FNR 0-8% and accuracy 96-100%. For ‘multiple breast cancer’ (n=688; 8 studies combining MF/MC cases): success rate for identification of a SLN 93-100%, SLN positivity rate 11-63%, FNR

6-13%, and accuracy 93-98%. For larger tumors (n=1646; 9 studies): success rate for identification of a SLN 86-100%, SLN positivity rate 42-59%, FNR 3-16.2% and accuracy 88-97.7%. For MF/MC and larger cancers overall non-SLN positivity rates were up to 82%; axillary recurrence rates were low but not often reported.

Conclusion: Although the evidence suggests that success rate and FNR of SLNB in MF/MC and larger tumors are similar to small unifocal cancers, node positivity rates are higher in these breast cancers and this translates to higher rates of understaging in real terms. High rates of non-SLN positivity for these tumors compared to rates for lower risk tumors mean that omitting ALND in the case of a positive SLNB risks leaving disease in the axilla more often than previously accepted. Thus the evidence supports the use of ALND in the majority of cases when the SLNB is positive. Women must be made aware that the high likelihood of positive axillary lymph nodes in MF/MC and larger breast tumors. Relying on SLNB-based management means accepting a higher risk of understaging and/or under treatment than when using SLNB based management for lower risk tumors.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-03.

Minimal access breast surgery: a single breast incision for breast conservation surgery and sentinel lymph node biopsy

AIMS

Minimal access breast surgery (MABS) is a procedure that completes breast conservation surgery (BCS) and sentinel node biopsy (SNB) through a single incision. It allows access to axillary sentinel nodes via the breast incision and also provides access to the internal mammary nodes (IMN) as well as other nodal sites when needed. The aims of this study are to describe the MABS approach and to evaluate its safety and efficacy in cases undergoing BCS and SNB (axillary or IMN) for treatment of breast cancer.

METHODS

The surgical technique for MABS is described. One hundred and three consecutive clinically lymph node negative patients undergoing BCS and SNB (axillary or IMN) were considered for MABS. Cases were classified according to the location of sentinel nodes dissected (axillary, internal mammary or other), the location of the tumour and whether MABS was used. The success of MABS was calculated based on the number of cases where BCS and SNB were completed through a single breast incision. Number of lymph nodes (LN) retrieved, rate of LN positivity, aesthetics and complications were documented.

RESULTS

Eighty-six percent of cases of BCS with axillary-only SNB were completed with MABS. For cases of BCS with axillary and IMN SNB, MABS was successful for BCS and IMN SNB in 97% of cases and for BCS and SNB from both nodal regions in 63%. There was only one case, a woman with breast prostheses, who required three separate incisions. When axillary-only SNB cases were completed with MABS, an average of 2.9 axillary LN per case with a 29% axillary LN positivity rate was seen. When axillary and IMN SNB were completed with MABS for both regions, an average of 3.0 axillary LN per case were retrieved with an axillary LN positivity rate of 65%. When separate axillary and breast incisions were made, 2.7 LN per case were removed with an axillary LN positivity rate of 30%. Aesthetics were excellent and there were no complications associated with reaching the nodes through the breast incision.

CONCLUSION

MABS is a feasible option for the majority of women undergoing BCS and SNB and it does not compromise the success of SNB.

The breast physician: an example of specialisation in general practice

General practitioners face the challenge of developing a career path and credentialling pathway for doctors working in special interest areas to ensure safe practice and to develop a professional profile for these groups. Breast physicians are one example. They care for women with benign and malignant breast disease and work in multidisciplinary teams in hospitals, clinics, private practice, and the breast screening program. The training and credentialling of breast physicians has recently been formalised by the Australasian Society of Breast Physicians with the introduction of a training program and fellowship in breast medicine.

Image-detected 'probably benign' breast lesions: a significant reason for referral from primary care

In Australia, and many health care provider systems, primary care physicians are the first to see women with breast symptoms and are responsible for making decisions on whether to investigate and when to refer to specialist teams. We present an audit of new patient referrals from primary care triaged to a 'low-risk' (low likelihood of cancer) clinic on the basis of benign findings. The most common reason for referral was 'breast lump' (38%) followed by 'image-detected' abnormality (26%.) We have identified that (outside of population screening services) many women are being referred from primary care to specialist clinics for management of screen-detected lesions considered benign on imaging. Further research is needed to identify the reasons for such referrals and to develop appropriate educational strategies and clinical policy, both for the primary care and the specialist breast practitioner.

The globin fragment LVV-hemorphin-7 is an endogenous ligand for the AT4 receptor in the brain

Angiotensin IV (Val-Tyr-Ile-His-Pro-Phe) has been reported to interact with specific high-affinity receptors to increase memory retrieval, enhance dopamine-induced stereotypy behavior, and induce c-fos expression in several brain nuclei. We have isolated a decapeptide (Leu-Val-Val-Tyr-Pro-Trp-Thr-Gln-Arg-Phe) from sheep brain that binds with high affinity to the angiotensin IV receptor. The peptide was isolated using 125I-angiotensin IV binding to bovine adrenal membranes to assay receptor binding activity. This peptide is identical to the amino acid sequence 30-39 of sheep betaA- and betaB-globins and has previously been named LVV-hemorphin-7. Pharmacological studies demonstrated that LVV-hemorphin-7 and angiotensin IV were equipotent in competing for 125I-angiotensin IV binding to sheep cerebellar membranes and displayed full cross-displacement. Using in vitro receptor autoradiography, 125I-LVV-hemorphin-7 binding to sheep brain sections was identical to 125I-angiotensin IV binding in its pattern of distribution and binding specificity. This study reveals the presence of a globin fragment in the sheep brain that exhibits a high affinity for, and displays an identical receptor distribution with, the angiotensin IV receptor. This globin fragment, LVV-hemorphin-7, may therefore represent an endogenous ligand for the angiotensin IV receptor in the CNS.

Aspiration of enlarged parathyroid glands for parathyroid hormone assay

Enlarged parathyroid glands were percutaneously aspirated under computed tomographic (CT) control in 7 patients, and levels of parathyroid hormone (PTH) and human thyroglobulin (HTg) were measured. All 7 patients had high levels of PTH in at least 1 specimen. It is concluded that the measurement of high concentrations of PTH in the aspirate from a cervical or mediastinal mass, with CT documentation of needle position, provides absolute localization of parathyroid masses.

The relationship between mortality and two indicators of morbidity

The Resource Allocation Working Party concluded that standardised mortality ratios are the best available indicators of geographical variations in morbidity. In this paper we give the results of a statistical analysis of the relationship between mortality and two indicators of morbidity, obtained from the 1971 census, for three age groups. The level of aggregation in the data is comparable with that at district or area level. Strong linear relationships are obtained, suggesting that it is reasonable to use mortality data in the RAWP formulae in applications at area of district level. However, this method of resource allocation should not be used in isolation from planning. A possible solution which reduces conflict between the two approaches is to incorporate mortality data in the planning indicators used to establish relative need and, in addition, to take due account of established patterns of service and local circumstances.

Association of childhood mortality with housing status and unemployment

The association between mortality at the ages of 0-4 and 5-14 years in the county boroughs of England and Wales for 1971, using Kendall's correlation technique, and a variety of socioeconomic indicators, was computed. Kendall's partial correlation technique was used to determine whether any association remained when the effect of social class and unemployment was kept constant. At ages 0-4 years there was a significant and positive association between mortality and low socioeconomic position, high density housing, inadequate housing amenities, and the unemployment rate (P less than 0.001). A significant association with the housing variables remained when the effect of socioeconomic status and unemployment was kept constant. Between the ages 5-14 years there was a statistically significant association (P less than 0.001) between mortality and housing density which was eliminated when the effect of social class was held constant. There was no association between unemployment and mortality in this age group.

Reactions of canadian women to the pap test and breast self-examination

The Canadian Cancer Society's public education program is based on the premise that early detection of cancer, followed by immediate treatment, saves lives. To promote this program the Society has developed the Seven Steps to Health which include "Have a Pap test" and "Do a monthly breast self-examination." To evaluate the effect of these two 'steps' on the female population of Canada, a public opinion poll was conducted which included a national random sample of women representative of age, educational and socio-economic levels and occupation. The poll showed that 76 percent of Canadian women have had at least one Pap test and 63 percent do breast self-examination regularly or occasionally. Significant relationships were revealed between social factors and participation in these health measures and reasons are elicited for non-participation.

Long-term assessment of extradural analgesia for the relief of pain in labour. I: Conducting a survey

A method of survey for the long-term assessment of extradural analgesia in labour is described. The difficulties and problems of collecting the data are discussed.

Socio-economic factors associated with unwanted births to married women: a geographical analysis using census indicators

The proportion of unwanted births to married women who were delivered in a district maternity hospital during a 3-month period in 1971 was computed for each ward in the administrative area. The percentage varied from 5 to 20% with an average of 10%. These results were compared with the distributions of socio-economic variables derived from the 1971 Census. Party was shown to be the most important indicator; Kendall's rank correlation coefficient was 0·56 (P <0·01). When the effect of parity was eliminated by the use of Kendall’s partial rank correlation coefficient, overcrowding and family structure were shown to be statistically significant (P <0·05).

The unwanted birth and the family planning service

In a survey in Coventry of 1079 post-natal patients, 11% (104) of married women and 46% (32) of single women stated that this birth was unwanted and emotionally distressing. The married women with unwanted births were the same age as other married women, but had substantially larger families. The single women with unwanted births were younger and all had left school at 16 years or below. Ten per cent of married women and 28% of single women with unwanted births had no knowledge of contraception and 28% of married women and 78% of single women with unwanted births had not used any contraceptive methods. Seventy-six per cent of married women and 78% of single women with unwanted births would have liked further professional advice.